Boari flap calycovesicostomy: a salvage procedure for giant hydronephrosis due to ureteropelvic junction obstruction.
AK Mandal, AK Hemal, S Vaidyanathan
Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India., India
A K Mandal
Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
The surgical management of two patients with giant hydronephrosis in a solitary kidney treated by Boari flap calycovesicostomy is presented. In one patient, this operation was done following unsuccessful previous pyeloplasty, while in the other this was done as the primary operation. Though free reflux was observed in both the cases, the refluxed contrast emptied satisfactorily after double voiding. No deterioration of renal function was noted during the follow-up period of 12 months.
|How to cite this article:|
Mandal A K, Hemal A K, Vaidyanathan S. Boari flap calycovesicostomy: a salvage procedure for giant hydronephrosis due to ureteropelvic junction obstruction. J Postgrad Med 1990;36:38-40
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Mandal A K, Hemal A K, Vaidyanathan S. Boari flap calycovesicostomy: a salvage procedure for giant hydronephrosis due to ureteropelvic junction obstruction. J Postgrad Med [serial online] 1990 [cited 2021 May 8 ];36:38-40
Available from: https://www.jpgmonline.com/text.asp?1990/36/1/38/876
Operative procedures for management of unsuccessful previous surgical attempts made to relieve ureteropelvic junction (M) obstruction or giant hydronephrotic kidneys represent a major challenge. If the contralateral kidney is normal, a nephrectomy may be the procedure of choice. However in presence of significant residual functional tissue, bilateral disease or solitary kidney, further reconstructive efforts are indicated.
We herein report two cases with giant hydronephrosis in solitary kidney salvaged by Boari flap calycovesicostomy.
Case 1: A 19-year-old girl had undergone Anderson Hynes pyeloplasty for right UPJ obstruction in September 1986 and ureteroneocystostomy for right ureterovesical junction obstruction in February 1987. An attempt to remove nephrostomy tube resulted in a palpable right kidney and episodes of fever with chills. Nephrostogram revealed persistent UM obstruction with large amount of residual urine even after six hours (See [Figure:1A]). She was detected to he hypertensive and was con trolled with propranolol 40 mg twice daily. Her routine investigations were normal except serum creatinine, which was 2 mg/dl. The left kidney was non-visualized on large dose intravenous urography and was found to he small and atrophic on ultrasonography. Thus a salvage procedure was planned on the solitary functioning right kidney. On exploration, the lower pole of the right kidney was found to be reaching almost to the pelvic brim and the cortical tissue appeared very thin. The distance between the lower pole of the kidney and the urinary bladder was measured with a ureteric catheter and a bladder flap of adequate length (11 cm) and width (7 cm and 4 cm at its base and apex respectively) was fashioned on the right side based on the inferior vesical pedicle. The flap was tubularised by two layers of sutures. A disc of thinned out parenchyma was excised from the lower pole of the kidney and the inferiop calyx was marsupialised. A direct anastomosis was then done between the tubularised bladder flap and marsupialised inferior calyx using interrupted sutures over a stent tube. The post-operative recovery was uneventful. IVU at 3 months' follow-up showed prompt excretion and good function on the right side (See [Figure:1B]). Cystogram revealed vesicocalyceal reflux but the refluxed contrast emptied satisfactorily on voiding (See [Figure:2A and [Figure:2B]). At 12 months' follow-up, her serum creatinine was 1 mg/dl and urine culture was sterile. She was practising double voiding and was doing well. However, at 18 months' follow-up, she was detected to have developed malignant hypertension, which progressed in spite of medical treatment.
Case 2: A 17-year-old girl presented in April 1988 with left flank pain of three months' duration. Physical examination revealed enlarged and tense, cystic left kidney extending from under the costal margin to the iliac fossa. Routine investigations were normal. IVU showed enlarged nephrographic density on the left side and nonvisualisation of the right kidney (See [Figure:3]). Ultrasonography confirmed absence of the right kidney. Exploration revealed hugely dilated left kidney with thinned out cortical tissue. Since more than half of the kidney was below the UPJ, a wide patent calycovesicostomy was planned to provide drainage to this solitary functioning kidney. A Boari bladder flap of 10 cm length and width of 6 cm and 4 cm at its base and apex respectively, was raised on the left side based on the inferior vesical pedicle. The flap was tubularised by suturing in two layers. The inferior calyx was marsupialised after excising a disc of thinned out cortical tissue from lower pole of the kidney. An end-to-end anastomosis was then performed between the marsupialised inferior calyx and the tubularised bladder flap using interrupted sutures. The anastomosis was stented and a nephrostomy tube was kept. Convalescence was uncomplicated. The stent was removed on the tenth post-operative day when contrast study confirmed no anastomotic leakage. The nephrostomy was removed after keeping it clamped for another 48 hours. Follow-up IVU at 3 months after calycovesicostomy showed good function and satisfactory drainage of the left kidney. Cystogram revealed free vesicocalyceal reflux (See [Figure:4]), which emptied completely on voiding (See [Figure:5]). At 12 months' follow-up, she was doing well with sterile urine and normal serum creatinine.
Dependent pelviureteric junction drainage would seem particularly important in cases with massive calyceal dilatation following severely compromized peristaltic activity in the collecting system. So when a lower calyx is hugely dilated and non-dependent to UPJ, drainage procedures at the lower calyx would logically be more effective. The ureterocalyceal anastomosis can be expected to yield a greater percentage of operative failures of poorly draining kidneys than do the other corrective procedures. Preventing post-operative stricture or kinking of the anastomosis is a formidable problem; most failures occur at this juncture. Boari flap calycovesicostomy ensures wide patent dependent drainage without a risk of anastomotic stricture and at the same time leaving behind the intact UPJ, which is the natural drainage channel.
A disadvantage of calycovesicostomy is vesicocalyceal reflux. But no glomerular or tubular functional and histological abnormalities have been noted in an experimental study using a canine model or in renal allotransplant patients with vesicopyclostomy or vesicocalycostomy,,.
The broad base of the Boari flap bears the brunt of the increased intravesical pressure and protects the kidney from the deleterious effects of reflux. However, these patients require a close long-term follow-up and timely intervention if renal function is threatened. This operation may be chosen more freely in females than in males, who with increasing age are prone to develop infravesical obstruction due to prostatic enlargement.
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